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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION !� 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in cosiliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ,► l Job Address I Z-3© Ay s I e 'h. D p�-t City =>+k Lot Size/Acreage Owner's Name n t lea er_54fv.. Address (2 3 0 RC42 /0 PI-2- Phone Contractor L&) k Ce V— Address License No. Phone PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK tGICULZ�WELL ER LDISPOSAL FLD. PROP. LINE FOUNDATION OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS I-) Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing f.l Domestic/Private ❑ Gravel Pack7 O Tra .y Ty of Casing_ Specifications op I'1 Public Cl Other fl De a Depth o out Seal Type of Gout I I Irrigation Approx. Depth I I Ea t o Surface Seal In d by Repair Work Done U Type of Pump H.P. k Done - Well Destruction ❑ Wall Diameter Sealing Material i Depth Depth Filler Material i Depth E OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ivr DESTRUCTION I I (No septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: �_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ T r yps/Mig Capacity �0 No. Compartments PKG. TREATMENT PLT.❑ r Method of Disposal Distance to nearest: Well 2- Foundation 143 Property Line 0 LEACHING LINE IN✓No. b Length of lines Total length/size LI)0 FILTER BED ❑ Distance to nearest: Well 2L S- Foundation t3 Property Line A _ SEEPAGE PITS I-Depth a- -Size 9 Z- Number SU PS LI Distance to nearest: Wella as Foundation Property Line 3 DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature candies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of ' nia.' The applic nt t ca for ctions. omplate drawing on reverse side. Signed Title: «P1? Date: Z� OR -"USE ONLY Application Accepted by `�CAArS� �- I Date - Area 2 Pit or Grout Inspection by Date Final Inspection by Date 1 / 1 Additional Comments: ; 7ylnr V0®LL -Wow/ ` lc-d{ r A&We ff Applicant - Return all copies to: San Joaquin County Public Health Services / uirr flit Environmental Health Permit/Services u We- 445 NSan Joaquin, P O Box 2009, Stkn, CA 95201 �,E �� IFEE N 0 AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY TE PERMIT'NO. On9Flcit alf- /�; �- . EH17.41(REV. M 5) EM ts•4s